Download pdf - For Lost, Stolen or Damaged Parcels Claim Information Sheet · Small Parcel/Cargo Insurance Buyer/Recipient Affidavit ... , Stolen or Damaged Parcels Claim Information Sheet ... ,

SmallParcel/CargoInsuranceBuyer/RecipientAffidavit ClaimNumber:______________

ForLost,StolenorDamagedParcelsClaimInformationSheetBuyers/RecipientsName:_______________________________________________________________StreetAddress/POBox______________________________________City________________________State/Province_____________________Postal/ZipCode___________Country_____________________Phone:______________________________Email_____________________________________________ClaimDetailLost/Damage/Incomplete______________________________________________________________IfItemisdamaged,pleasedescribeandattachpictureofdamage:____________________________________________________________________________________________________________________ Describeconditionofpackage:_________________________________________________________________________________________________________________________________________________SellerInformationName:________________________________________________________________________________Phone:__________________________________Email_________________________________________IherebycertifythatallinformationonthisformisaccurateandtruthfulunderFederalLawandunderpenaltyofperjury,underthelawsofthestateofCalifornia.Thesubmissionofafalse,fictitiousorfraudulentstatementmayresultinimprisonmentofupto5yearsandafineofupto$10,000(18USC1001).Inaddition,acivilpenaltyofupto$5,000,andanassessmentoftwicetheamountfalselyclaimedmaybeimposed(31USC3802).Buyer/RecipientSignature:_______________________________________Date:___________________Warning:Anyfraudulentclaimswillmaketheshipperand/orconsigneeliableforanyprosecutionformailfraudunderthefederalcrimecode.

Shouldtheinsuredand/orshippersubmitafalse,fictitiousorfraudulentstatement,itwillresultintheclaimsbeingdenied.

InsureShip 3211CahuengaBlvd.WestSuite200,LosAngeles,CA90068Phone:(866)701-3654/(818)303-9255Fax:(877)859-5858Email:[email protected]